The Challenges of Menopause
Menopause is an important time of transition for every woman, but when you also have Hashimoto’s it can be particularly challenging.
I recently attended a lecture called the Neuroendocrine Immunology of Perimenopause written by Dr. Datis Kharrazian. I learned a ton and I’ll share some of it, but I must say I was disappointed by the lack of references to Hashimoto’s and hypothyroidism. Fortunately, that disappointment led me to explore these topics further with Hashimoto’s in mind.
In this post we examine the physiological changes that women go through during this time of their lives and we show how these changes can be impacted by Hashimoto’s and hypothyroidism. And, as always, we explore why it matters.
Perimenopause Isn’t a Disease
For many women in the US and in cultures that have adopted our diet and lifestyle, menopause has become something to dread. It is associated with physical, emotional and psychological decline and for some also brings with it an increased risk of numerous other conditions.
And these other conditions are not minor. They include:
Cardiovascular disease and stroke
Dementia and Alzheimer’s disease
Autoimmune disease (Yes, that includes Hashimoto’s)
However, this is not true for everyone. And it is a relatively new phenomena, for much of recorded history and in many other cultures throughout the world menopause is just another transition in life.
Like the transitions from childhood to adolescence and adolescence to adulthood, the transition to menopause is just a transition. It lasts about a year and life goes on without major declines in health and well being.
Why Are Women in Western Cultures Different?
Studying menopause across cultures is difficult, but the research has shown some possible differences in different countries and ethnic groups.
For example, Japanese women may report fewer hot flashes because they have a diet high in soy (which includes phytoestrogens) (Freeman & Sherif, 2007).
Within the medical literature there are different views on the relationship between body mass index (BMI) and hot flashes, with some studies linking a protective effect of body fat, others the opposite, and some finding no connections (Andrikoula & Prevelic, 2009; Chedraui et al., 2007; Freeman et al., 2001; Schwingl et al., 1994; Whiteman et al., 2003).
However more recently, Thurston et al. (2009) have found that body fat gains during the menopause, rather than high or low BMI, were associated with hot flash symptoms.
Women who smoke and have sedentary lifestyles have been found to report more menopausal symptoms. And this makes sense when you look at what is happening physiologically which we will explore shortly.
Reproductive history may also be relevant; for example, in the Mayan culture women marry between the ages of 14 and 18 years, have many children and few repetitive menstrual cycles.
Mayan women usually enter the menopause in their early to mid 40s, which is about 10 years earlier than women in the UK and North America (Beyene, 1989).
Common Physical Changes Across Cultures
Regardless of your cultural background, there are some important changes that take place in the body during peri-menopause and menopause and these can be amplified when you also have Hashimoto’s.
Of course, everything in the body happens for a reason and is caused by specific mechanisms. For example, in a moment I’ll explore the most common perimenopausal symptoms and the mechanisms or causes that lead to them.
But before I do, I want to share an observation that is a really important mindset for making the transition to menopause far gentler and less destructive.
Treat Your Body During Perimenopause Like You Would in Pregnancy
After looking at all this research, one thing I realized is that the problems and more severe symptoms that are caused by this transition are entirely preventable if you prepare for them and take action before they happen.
And even if you have already gone through this transition, taking these preventative measures will also reduce your risk of developing some of the serious conditions we mentioned above.
Here’s a simple way to think about it: treat your body in the years leading up to perimenopause just like you would when you are pregnant. Don’t smoke, don’t drink excessive amounts of alcohol, don’t over indulge in refined sugars and junk food.
Reduce stress, get moderate amounts of exercise and heal the parts of your body that may be compromised. In particular, focus on healing your brain, your gut, your adrenals and do everything you can to reduce inflammation.
If you have read any of our other materials or my new book, Roadmap to Remission, you will notice that these are all important areas to heal when you have Hashimoto’s, as well.
Common Symptoms and their Causes During Perimenopause
Here’s an overview of the most common symptoms of perimenopause and some of their potential causes.
1. Systemic inflammation and pain: This is caused by surges in certain immune cells and proteins called cytokines. Cytokines like IL-6, IL-1 and TNF-alpha are all implicated in Hashimoto’s, as well.
2. Multiple food sensitivities, gastrointestinal symptoms. These are often caused by Intestinal permeability or “leaky gut”: This maybe caused by declines in estrogen, increases in cortisol production, hypothyroidism and dysfunction in the gut. Intestinal permeability is ground zero for autoimmunity, as well.
3.More stress, poor sleep, fatigue during the day. The adrenals have to do additional work when other female hormones, like estrogens decline. Adrenals issues are also very common with Hashimoto’s.
4. Poor circulation, cold hands and feet, poor nails beds, fungal overgrowth in nail beds. This is caused by problems with peripheral circulations, especially in the small vessels. And may be due to altered nitric oxide function. These symptoms are also very common with Hashimoto’s.
5. Brain fog, depression, memory loss and poor cognitive function. This is due to inflammation in the brain and deficiencies or declines in neurotransmitters. These are some of the most common symptoms of Hashimoto’s.
6. Hot flashes, night sweats. A hallmark of perimenopause caused by altered FSH (follicle stimulating hormone) and feedback from the ovaries. This is a less common symptom of Hashimoto’s but something many women experience.
7. Poor bone density. This is caused by problems in osteoclast or bone cell formation and other issues. It is also a very real concern for Hashimoto’s patients, as well. One of the major causes of this breakdown in bone health is the cytokines that we spoke about above.
Let’s Look a Little Deeper into these Mechanisms and What to Do About Them
Now, let’s dive a little deeper and look at what to do about each of these symptoms.
Cytokine Surges: Immune System on Fire
Hashimoto’s is, as we all know, an autoimmune disease. One of the hallmarks of autoimmunity is an overly excited immune system and this can be seen in high levels of substances called cytokines.
The root of autoimmunity and the damage it causes in the body is inflammation. many of these cytokines help promote this inflammation.
When you go through the changes of menopause, estrogen levels decline and estrogen calms inflammation. So if you already have an overexcited immune system producing lots of cytokines, you may have a major surge during peri-menopause and menopause.
Other signs of cytokines include:
1. Brain inflammation: brain fog is a clear sign
2. Body fat: adipose tissue produces cytokines
3. Free radicals: this causes inflammation
4. Stress: it’s very inflammatory
Declines in estrogen can lead to cells being more responsive to cytokines and more receptors and messengers that just amplify this inflammation. This can stay elevated even after estrogen replacement therapy.
Leaky Gut: Ground Zero
In my opinion, the breakdown of the intestinal lining that results in leaky gut and intestinal permeability is an important battlefield in healing Hashimoto’s.
Well, declines in estrogen production can lead to breakdowns in the gut, as well. When this happens you may develop leaky gut, as wells leaks in the blood brain barrier.
And these leaks cause the immune system to get all fired up and it creates more of the cytokines we just mentioned above.
It’s a classic vicious cycle made worse by estrogen levels declining.
Adrenals to the Rescue
During and after the transition of menopause the adrenal glands step in and take over for the ovaries.
Essentially, what happens is this.
FSH (Follicle Stimulating Hormone) receptors in the ovaries begin to lose sensitivity during perimenopause. This leads to changes in levels of FSH and estradiol.
The adrenals, in turn, step in and create more adrostenedione, a steroid hormone and this is converted to estrogen by adipose (fat) tissue. It’s the body’s way of compensating for declines in estrogen.
Obviously, there is a potential problem here if the adrenals are already taxed or exhausted. A lot more demands are made on them in perimenopause.
So adrenal health is very important prior and during this transitional time.
Circulatory issues are very common with patients with Hashimoto’s. This is due to many factors including systemic inflammation, and the tendency for the body to compensate for hypothyroidism by bringing blood from the extremities into the body.
This sometimes occurs because the body is trying to regulate blood pressure and hypothyroidism, at least at first, can cause low blood pressure.
Another issue that leads to poor circulation in the extremities is lower plasma volume. This is caused by the capillaries becoming more permeable and when this happens albumin and water can leak from the vessels into the intestinal spaces.
This causes swelling from edema and water retention, often in the ankles and lower legs. Of course increased swelling is going to impact circulation, as well.
I have written quite a bit about the profound impact of Hashimoto’s on the brain and it is an area that I am very passionate about. If you aren’t familiar with this, here’s a previous post on brain fog.
In a nutshell, hypothyroidism and autoimmunity can both lead to inflammation in the brain. This is caused by many things including breakdowns in the blood brain barrier, blood sugar imbalances, adrenal stress and more. In addition, as estrogen declines during menopause and peri-menopause the body loses it’s anti-inflammatory effects.
The result of all of this is a massive reaction by the brain’s immune cells, the microglia. These cells have no real off switch so once they get activated it can be difficult to calm them down. And when they are called into action they can cause more inflammation and destruction of brain cells and neurons.
All of this results in that all too familiar feeling of brain fog, difficulty concentrating, focus problems and all the associated emotional issues of isolation, depression and anxiety.
The exact mechanism for hot flashes is not known. But there are many interesting theories.
Robert R. Freedman has studied hot flashes for 25 years. He and his colleagues measured skin temperature, blood flow, and skin conductance (an electrical measure of sweating) in menopausal women before, during, and after hot flashes.
They found that women who have hot flashes have a lower tolerance for small increases in the body’s core (innermost) temperature than women who don’t have hot flashes. The body tries to keep its core temperature within a comfortable “thermoneutral zone.” When our core temperature rises above the zone’s upper threshold, we sweat; when it drops below the lower threshold, we shiver.
Women who don’t have hot flashes have a thermoneutral zone of several tenths of a degree centigrade. But in women with hot flashes, this thermoneutral zone is so narrow, it’s “virtually nonexistent,” according to Freedman.
As a result, small variations in core body temperature — by as little as one-tenth of a degree centigrade — that don’t trouble some women trigger hot flashes (and chills) in others.
What causes the thermoneutral zone to narrow? One theory is that elevated levels of the brain chemical norepinephrine are involved. Norepinephrine has been shown to reduce the thermoneutral zone in animals.
Interestingly, patients with hypothyroidism often have elevated levels of norepinephrine. One theory is that hypothyroidism can cause changes in blood flow (hemodynamics). One thing the body does to compensate for less blood flow is to release more norepinephrine. So you can see, hypothyroidism could make this symptom worse.
Poor Bone Density
Oesteoporosis is a major concern for both Hashimoto’s and menopausal women. One common factor in both is the IL-6. This cytokine is a major predictor of bone loss in women, especially in the first decade of menopause.
These pro-inflammatory immune proteins are also involved in the body’s reabsorption of bone. In addition, one of the roles of estrogen is to slow the break down of bones.
What the research seems to suggest is that the combination of increased cytokines and decreased estrogen leads to more bone loss. It’s a perfect storm of inflammation and natural transitions.
With thyroid disorders bone loss is also a major issue. Too much thyroid hormone can lead to to increased bone mineral resorption and calcium loss through kidneys. (One reason why it’s so important to not take too much thyroid hormone.)
Also, hypothyroidism can lead to problems with the bones. It seems that there is increase in bone density in adult subjects with hypothyroidism, but the bone quality is poor which is responsible for the possible increase in fracture in these patients.
What Do You Do?
Isn’t that always the million dollar question?
Well, if you’ve read any of my writing you’ll know my answer it, “It depends.” And it does, you have to address the problems.
So, let’s review the problems and look for common issues. That will tell us what we should do.
Here are the main issues we identified:
Ok, well we identified that inflammation and pro-inflammatory cytokines are at least partly responsible for brain fog, hot flashes, bone loss and, of course systemic inflammation.
So, dealing with inflammation, the root of all evil is pretty darn important.
What can we do for inflammation?
Well, boosting Vitamin D is super important, especially because of it’s role in bone health. Other anti-inflamatories like turmeric, glutathione, resveratrol, and also avoiding foods that are pro-inflammatory like gluten, dairy and soy.
2. Declines in Estrogen:
We also noted that declines in estrogen can lead to all of the above, plus leaky gut. And there are 2 ways to deal with this. Heal and empower the adrenals to take over, or supplement with hormone replacement therapy.
Hormone replacement therapy comes with it a number of risks. Breast and ovarian cancer being top of the list.
Also, according to a study in the New England Journal of Medicine, June 7th 2001 on women treated for thyroid cancer found that about 40% of women taking thyroid hormone had decreases in their blood levels of thyroxine. These levels were low enough to trigger hypothyroid symptoms, such as low energy and feeling tired, sluggish, and cold, or to put them at risk for regrowth of thyroid cancer.
In addition, estrogen has also been linked to increased metastasis of thyroid cancer. And radioactive iodine therapy has been linked to a increased risk of breast cancer in some studies.
Some herbs that are helpful for healthy estrogen metabolism are: tribulus, panax ginseng, dang guy, black cohosh, redeliver leaf, isoflavones from soy (sometimes called phytoestrogens may also help, but must be used cautiously with Hashimoto’s patients), cruciferous vegetables can also helpful in estrogen metabolism, and vitamins that support methylation like B6, B12 and folic acid are also helpful for clearing out dangerous estrogen metabolites.
3. Leaky Gut
In my opinion, leaky gut is ground zero for autoimmunity and Hashimoto’s. It also happens to be a major factor in preimenopause. Estrogen reduces permeability of the intestines by strengthening the tight junctions of the intestinal walls.
As etsrogen levels decline, intestinal permeability risk increases. Add Hashimoto’s and hypothyroidism to the mix and you have a potent recipe for leaky gut.
To heal leaky gut avoid the foods that can make it worse: eliminate gluten, dairy and soy. Consider trying a diet like the Autoimmune Paleo diet. Drink bone broth, kombucha tea and water keifer.
4. Adrenal Health
If you elect not to do estrogen replacement therapy, then your adrenals become very important for your health and well being.
And stress management becomes absolutely essential.
For the adrenals: phosphatidylserine, adaptogenic herbs like Siberian ginseng, holy basil, rhodiala are beneficial. As is licorice root, DHEA, B vitamins, B 1 and B 2 and more.
All of these herbs and vitamins shouldn’t be taking randomly in what I like to call “the supplement lottery”. You should first do a proper assessment of each system of the body and then determine which supplements may be appropriate.
Also, having a real stress strategy and not just an abstract understanding of the destructive effects of stress is also critical. Yoga, qi gong, meditation, prayer, massage therapy, acupuncture, walking in Nature, having fun are effective for treating stress.
Any and all of these activities must become a regular part of your life. In fact, if you do anything you should err on the side of too much relaxation and stress treatment. Stress is very inflammatory, not treating it is just not an option.
I provide a detailed discussion of proper assessment in my new book, Roadmap to Remission, A Practical Guide to Hashimoto’s Healing
The Neuroendocrine Immunology of Perimenopause, 2015, Dr. Datis Kharrazian
http://www.natural-menopause-journey.com/perimenopause-symptoms-and-culture.html: menopause differences in different cultures
Freeman, E.W., Sammel, M.D., Grisso, J.A. et al. (2001). Hot flashes in the late reproductive years: Risk factors for African American and Caucasian women. Journal of Women’s Health & Gender-Based Medicine, 10(1), 67–76.
Freeman, E.W., Sammel, M.D., Lin, H. et al. (2005). The role of anxiety and hormonal changes in menopausal hot flashes. Menopause, 12(3), 258–266.
Freeman, E. & Sherif, K. (2007). Prevalence of hot flushes and night sweats around the world. Climacteric, 10, 197–214.
Andrikoula, M. & Prevelic, G. (2009). Menopausal hot flushes revisited. Climacteric, 12, 3–15.Avis, N.E., Crawford, S.L. & McKinley, S.M. (1997). Psychosocial behavioural and health factors related to menopause symptomatology. Womens Health, 3, 2, 103–120.
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Hunter, M.S., Gupta, P., Papitsch-Clark, A. & Sturdee, D.W. (2009). Mid–aged health in women from the Indian subcontinent (MAHWIS): A further quantitative and qualitative investigation of experience of menopause in UK Asian women, compared to UK Caucasian women and women living in Delhi. Climacteric, 12(1), 26–37.
Thurston, R.C., Sowers, M.F.R., Sternfeld, B. et al. (2009). Gains in body fat and vasomotor symptom reporting over the menopausal transition. The Study of Women’s Health Across the Nation. American Journal of Epidemiology, 170(6), 766–774.
Beyene, Y. (1989). From Menarche to menopause: Reproductive lives of peasant women in two cultures. Albany, NY: State University of New York Press.
Freedman, RR. Seminars in Reproductive Medicine 2005; 23 (2): 117-125.
http://www.ncbi.nlm.nih.gov/pubmed/19433574 Estrogen and Leaky gut
http://www.ncbi.nlm.nih.gov/pubmed/11844745 Changes in proinflammatory cytokine activity after menopause
http://www.ncbi.nlm.nih.gov/pubmed/9507566 Changes in enzymatic antioxidant defense system of women after menopause
http://www.ncbi.nlm.nih.gov/pubmed/11344203 IL-6 as a predictor of bone loss
http://www.ncbi.nlm.nih.gov/pubmed/6467635 : Plasma elevations of norepinephrine
http://hyper.ahajournals.org/content/5/1/112.full.pdf Hypothyroidism and hypertension
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169869/ Thyroid disorders and Bone Loss
http://www.hindawi.com/journals/ije/2013/941568/ Estrogen and Thyroid Cancer metastasis
http://www.ncbi.nlm.nih.gov/pubmed/12182054 : Hormone Replacement therapy after thyroid surgery